Recognizing their being and ours

I was a little reluctant to begin reading The Emperor of all Maladies (now a PBS documentary) because it seemed to be too long. But it was both a fascinating and fast read. That cancer was a disease of process rather than of an organ system was a great insight. The history of cancer from an imbalance of humors to our current understanding at the transcription level is also a study of evolving Western thought about disease.

It is a Western belief (reductionism), that a disease can be broken down into its constituent parts, and that conceit has allowed us to make great strides in our understanding. It has allowed us to focus, reducing noise and enhancing the signal we are pursuing. But it is increasingly clear that to abstract a process into its components has unintended consequences. Heisenberg’s principle applies equally to medicine as to physics. Measurement does influence the system we are measuring; and what we are capable of measuring influences what we see.

Abraham Verghese has long advocated for physicians to return to the bedside, to caring for our patients in an older and more intimate way. In a recent Medscape interview, prompted by his American College of Cardiology (ACC) keynote address, he talks about the changes measurement has made in the system of healthcare in two ways.

“It strikes me that we have the somewhat paternalistic assumption that the heart we’re dealing with is the real one because we can see it and measure it, but who is to say?.... It’s clear that the prevailing heart out there isn’t the one that you and I deal with. The prevailing heart is very much the way patients express their deepest feelings. It’s where they think their beliefs and their love reside. I always had the sense that we’re dealing with two hearts. To focus on one without paying attention to the other is to miss something.”

Verghese captures in a very poetic way the growing distance between what we can measure and what is worth measuring. Our increasing ability to quantify dis-ease and its markers gives us more precision but we sacrifice an understanding of the whole. I saw this the other day in a LinkedIn discussion around vascular surgery in the elderly. The comments all centered on ‘amputation-free survival’, a measured quantity of ‘quality’. There was no discussion of the functional outcome for any of the ‘amputation-free’ patients. To be amputation free, but bedbound because of frailty or wound care is really little different than having undergone the amputation. It is difficult to say as a trained surgeon, but sometimes less is more. The key is returning to caring for our patient, not our chosen organ system.

But the measurement process impacts us in a different way.

“…but the more things we can bring to bear at the bedside, the more likely we’ll practice a little more cost-effectively and the less likely we are to run to consultants. A lot of the inefficiencies in our healthcare have to do with the fact that people aren’t sure of themselves at the bedside and never confident of saying, “No, we don’t need to do more.” It’s much easier to say let’s get this test, let’s call so and so.”

In our reductionist quest for mastery we have gain great knowledge and insight, but this focused understanding has come at the price of mastery and understanding of the whole. At some level it seems we have lost confidence in our clinical abilities to listen and touch. And this lost confidence often extends to our relationships with our co-workers. We needn’t forsake our hard won mastery; we need to meld our knowledge with the motivations that initially brought us to healthcare. Verghese in his keynote address more eloquently summarizes this solution when he reads from e.e. Cummings. (The entire 20-minute talk can be found here)